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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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On-Call and Out-of-Hours Management Policy

1. Purpose

The purpose of this policy is to ensure the continuous provision of safe, effective, responsive, caring and well-led care at {{org_field_name}} outside normal office hours. The policy sets out the arrangements for competent management support, decision-making, communication, escalation and record keeping during evenings, nights, weekends and public holidays.

{{org_field_name}} operates an on-call and out-of-hours management system to ensure that staff working in the care home have timely access to advice and senior decision-making when urgent issues arise. This includes, but is not limited to, deterioration in a resident’s health, safeguarding concerns, medicines incidents, staffing shortages, environmental risks, fire, infection prevention and control concerns, accidents, incidents, deaths, hospital transfers, missing residents, DoLS/Mental Capacity Act concerns, or any event that may affect the safety, welfare, dignity or continuity of care of residents.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Quality Commission (Registration) Regulations 2009, CQC Fundamental Standards and CQC’s current assessment framework.

2. Scope

This policy applies to all staff members, including care workers, senior carers, team leaders, the Registered Manager, and other designated individuals participating in the on-call rota at {{org_field_name}}.

This policy applies to all out-of-hours arrangements within the care home, including residential care, nursing care where applicable, respite care, end-of-life care, emergency admissions, night shifts, weekends and public holidays. It applies to all staff, agency workers, volunteers, contractors where relevant, the Registered Manager, Deputy Manager, senior care staff and any person designated to provide on-call support.

For the purposes of this policy, “on-call person” means the competent and authorised person designated by {{org_field_name}} to provide out-of-hours management support, advice, escalation and decision-making. The on-call person must not be used as a substitute for safe staffing levels in the home.

3. Related Policies

• CH04 – Good Governance
• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH18 – Risk Management and Assessment Policy
• CH19 – Emergency and Business Continuity Plan
• CH24 – Management of Accidents, Incidents, and Near Misses Policy
• CH25 – Notification of Other Incidents Policy
• CH27 – Staff Supervision, Training, and Development Policy

4. Legal and Regulatory Framework

This policy must be read and applied in accordance with the following legislation, regulations and guidance, as amended or replaced:

• Health and Social Care Act 2008
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• Care Quality Commission (Registration) Regulations 2009
• Care Act 2014
• Mental Capacity Act 2005 and Deprivation of Liberty Safeguards
• Safeguarding Vulnerable Groups Act 2006
• Health and Safety at Work etc. Act 1974
• Management of Health and Safety at Work Regulations 1999
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, where applicable
• Data Protection Act 2018 and UK GDPR
• Equality Act 2010
• Human Rights Act 1998
• CQC Fundamental Standards
• CQC current assessment framework and quality statements
• Oliver McGowan Code of Practice on statutory learning disability and autism training

The on-call system supports compliance with, in particular, Regulation 9 Person-centred care, Regulation 9A Visiting and accompanying, Regulation 10 Dignity and respect, Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance, Regulation 18 Staffing, Regulation 19 Fit and proper persons employed, Regulation 20 Duty of candour and Regulation 20A Display of performance assessments.

5. Policy Statement and Responsibilities

Continuous and Responsive Care Provision

{{org_field_name}} is committed to maintaining safe, effective and responsive care 24 hours a day. The on-call system ensures that a competent and authorised senior person is available outside normal office hours to provide advice, support, decision-making and escalation where urgent operational, clinical, safeguarding or environmental concerns arise.

The on-call person must support, but must not replace, the duty of the staff on shift to deliver safe care, follow care plans, respond to emergencies, contact emergency services, seek medical advice, report safeguarding concerns and record actions taken. Staff must not delay calling 999, NHS 111, the GP out-of-hours service, the community nursing team or other emergency professionals while waiting for the on-call person where urgent action is required to protect life, health or welfare.

The on-call system must be robust, reliable and tested. A named primary on-call person and a named secondary escalation contact must be available for each out-of-hours period. The Registered Manager retains overall responsibility for ensuring that the on-call arrangements are safe, effective and monitored.

Appointment, Competence and Training of On-Call Persons

Only staff who are suitably qualified, competent, experienced and authorised by the Registered Manager may be included on the on-call rota. Before undertaking on-call duties, the person must demonstrate that they have the knowledge, skills, confidence and authority to make safe decisions and to escalate concerns appropriately.

The on-call person must have:

• A clear understanding of the needs, risks, communication needs and care arrangements of residents living at {{org_field_name}}
• Access to current care plans, risk assessments, staff rotas, dependency information, emergency contacts and relevant policies
• Knowledge of safeguarding adults procedures, local authority safeguarding referral arrangements and whistleblowing procedures
• Knowledge of Regulation 12 safe care and treatment, Regulation 13 safeguarding, Regulation 17 good governance, Regulation 18 staffing, Regulation 19 fit and proper persons employed, Regulation 20 duty of candour and CQC Registration Regulation 18 notification of other incidents
• Knowledge of the Mental Capacity Act 2005, best-interest decision-making and Deprivation of Liberty Safeguards, where relevant to urgent out-of-hours decisions
• Knowledge of medicines escalation procedures, including medication errors, missed medicines, controlled drugs concerns and urgent pharmacy support
• Knowledge of infection prevention and control escalation, outbreak reporting arrangements and isolation precautions
• Knowledge of fire, flood, utilities failure, environmental emergency and business continuity arrangements
• Knowledge of the provider’s complaints, accident, incident, death of a resident, missing resident and statutory notification procedures
• Training in equality, diversity, human rights, dignity, privacy, confidentiality, information governance and record keeping
• Learning disability and autism training appropriate to their role and responsibilities, in line with statutory requirements and the Oliver McGowan Code of Practice
• The authority to arrange additional staffing, approve emergency agency cover, contact relatives where appropriate, escalate to the Registered Manager or Nominated Individual, and initiate business continuity procedures.

The Registered Manager must ensure that all on-call persons receive induction, competency assessment, supervision, reflective learning and refresher training. Competence to undertake on-call duties must be reviewed at least annually and sooner where there is a serious incident, safeguarding concern, complaint, performance concern, change in legislation or change in the service.

On-Call Responsibilities

The on-call person must:

• Be contactable by telephone at all times during the on-call period and respond promptly to calls
• Ensure they have sufficient battery, signal, charger access and contingency arrangements to remain contactable
• Keep access to relevant systems, including resident care plans, risk assessments, staffing rotas, dependency tools, emergency contacts, business continuity plans and incident reporting systems
• Provide advice and support to staff while ensuring that urgent clinical or emergency situations are escalated immediately to the appropriate emergency or healthcare service
• Support staff to manage serious deterioration in a resident’s health, including falls with injury, chest pain, breathing difficulties, suspected stroke, sepsis concerns, choking, serious bleeding, acute confusion, repeated vomiting, collapse or any other urgent health concern
• Support staff to escalate medicines concerns, including missed doses, administration errors, refusal of critical medicines, suspected overdose, controlled drugs discrepancies or lack of access to prescribed medicines
• Support staff to respond to safeguarding concerns, including suspected abuse, neglect, self-neglect, organisational abuse, unexplained injury, financial abuse, sexual abuse, discriminatory abuse, domestic abuse or improper treatment
• Ensure that allegations of abuse or serious incidents are escalated to the Registered Manager and safeguarding authority without delay, in line with local safeguarding procedures
• Support decision-making where a resident lacks capacity, ensuring that the Mental Capacity Act 2005 is followed and that urgent best-interest decisions are recorded
• Support staff where there are concerns about restraint, restriction, deprivation of liberty, distressed behaviour or behaviour that may place the resident or others at risk
• Manage urgent staffing risks, including sickness absence, failure of staff to attend duty, unsafe skill mix, agency staff concerns, fatigue or dependency changes
• Authorise emergency staffing changes, additional cover or agency use where required to maintain safe care
• Support lone workers, night staff and staff who are distressed following an incident
• Ensure that relatives, representatives, advocates or professionals are contacted where appropriate and lawful
• Ensure that residents’ privacy, dignity, confidentiality, rights and choices are maintained during any emergency response
• Consider whether the issue triggers a statutory notification to CQC, safeguarding referral, police referral, RIDDOR report, local authority notification, commissioner notification or Duty of Candour process
• Record all calls, decisions, advice, escalation, actions taken, persons contacted, timescales and follow-up requirements in the On-Call Log
• Escalate immediately to the Registered Manager, Nominated Individual, provider, emergency services, safeguarding authority or other relevant professional where the risk cannot be safely managed at on-call level
• Ensure that a handover is provided to the Registered Manager or delegated senior person at the start of the next working period.

Staff Responsibilities When Contacting On-Call

Staff must contact the on-call person without delay where they require urgent management advice or authorisation. However, staff must not wait for permission from the on-call person before taking immediate action to protect a resident from harm. Where there is a risk to life, serious injury, serious deterioration in health, fire, violence, missing resident, suspected crime or any other emergency, staff must contact the emergency services first and then inform the on-call person as soon as possible.

Staff must provide the on-call person with clear and accurate information, including the resident’s name, location, immediate risk, what has happened, actions already taken, professionals contacted, current staffing position, whether relatives or representatives have been informed, and what support or decision is required.

Staff must record the event in the resident’s care record and in the relevant accident, incident, safeguarding, medicines, body map, daily notes or other reporting system before the end of the shift, unless this is not possible due to the emergency. Where recording is delayed, the reason must be documented.

Communication and Accessibility

The on-call number and secondary escalation number must be available to all staff on duty, displayed in the agreed staff-only location, included in the emergency contact file and accessible in the event of IT failure. Staff must know how to access the on-call system before working unsupervised, including at night, weekends and public holidays.

The on-call system must operate from the end of the normal working day until the start of the next working day and for the full duration of weekends and public holidays. Any changes to the on-call contact number must be communicated to all staff before the change takes effect.

Staff must contact the on-call person immediately in the event of:

• A resident becoming seriously unwell or requiring urgent medical advice
• A death, expected or unexpected
• A fall, injury, accident, incident or near miss requiring management advice
• Suspected or alleged abuse, neglect or improper treatment
• A medication error, missed medicine, controlled drug concern or urgent medicines access issue
• A resident going missing or being absent without explanation
• A fire, flood, power failure, heating failure, lift failure, water failure, gas concern, security breach or environmental hazard
• A staffing shortage, unsafe staffing level, unsafe skill mix or agency staff concern
• A complaint or serious concern raised by a resident, relative, representative, professional or visitor
• A visiting or accompanying concern that may affect a resident’s rights, safety or wellbeing
• A Mental Capacity Act, best-interest, restraint or Deprivation of Liberty Safeguards concern
• Police, ambulance, fire service, GP, NHS 111, community nurse, safeguarding, local authority or commissioner involvement
• Any incident that may require CQC notification, safeguarding referral, Duty of Candour response or provider escalation.

Incident, Notification and Escalation Protocols

All emergencies, serious concerns and significant out-of-hours events reported to the on-call person must be managed in line with {{org_field_name}}’s incident reporting, safeguarding, statutory notification, Duty of Candour and business continuity procedures.

The on-call person must consider whether the matter requires any of the following:

• Immediate emergency response by 999, fire service, police or ambulance
• Urgent medical advice from NHS 111, GP out-of-hours, community nursing team, palliative care team or other healthcare professional
• Safeguarding referral to the local authority
• Police referral where a crime is alleged or suspected
• CQC statutory notification, including notification of death, serious injury, abuse or allegation of abuse, police involvement, DoLS outcome, unauthorised absence, or an event that stops or may stop the service running safely and properly
• Notification to commissioners, local authority, Integrated Care Board, environmental health, UKHSA or other agencies where applicable
• RIDDOR reporting, where applicable
• Duty of Candour response where a notifiable safety incident has occurred
• Internal investigation, root-cause analysis, lessons learned review or provider-level escalation.

For clarity, references to “Regulation 18 – Notification of other incidents” in this policy mean Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. This is separate from Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which relates to staffing.

All incidents must be recorded accurately, contemporaneously and in sufficient detail to show what happened, who was involved, what immediate action was taken, who was informed, what decisions were made, whether the resident and/or representative was informed, whether Duty of Candour applies, whether external notifications were required, and what follow-up action is needed.

Duty of Candour

Where an incident may meet the threshold for a notifiable safety incident, the on-call person must ensure that the Registered Manager is informed without delay. The Registered Manager, or delegated competent person, must ensure that the Duty of Candour process is followed in line with Regulation 20.

This includes acting in an open and transparent way, providing a truthful account of what is known at the time, offering an apology where required, explaining what further enquiries or investigations will take place, keeping the resident and/or relevant person informed, and maintaining a written record of all Duty of Candour actions.

The on-call person must not make speculative statements, assign blame or provide inaccurate reassurance. Where information is incomplete, this must be explained honestly and followed up as further facts become available.

Safeguarding Out of Hours

Any safeguarding concern identified out of hours must be acted on immediately. The on-call person must support staff to make the resident safe, seek urgent medical help where required, preserve evidence where a crime may have occurred, record factual information, and escalate to the Registered Manager and local authority safeguarding team in line with local safeguarding procedures.

Where there is an immediate risk of harm, staff must contact emergency services without delay. The on-call person must ensure that any allegation of abuse, neglect or improper treatment is not investigated internally before the appropriate safeguarding referral is made, unless immediate fact-finding is necessary to protect the resident or others from harm.

The on-call person must consider whether the concern also requires CQC notification, police referral, commissioner notification, staff suspension or redeployment, whistleblowing support, family/representative communication, Duty of Candour or a formal internal investigation.

Mental Capacity, Consent and Deprivation of Liberty Out of Hours

Where an urgent decision is required and there is reason to believe that a resident may lack capacity to make that specific decision at that time, staff and the on-call person must follow the Mental Capacity Act 2005. Capacity must be decision-specific and time-specific. The resident must be supported as far as possible to make their own decision.

Where the resident lacks capacity for the specific decision, any action taken must be in the resident’s best interests, be the least restrictive option, and be clearly recorded. The record must include the decision required, the reason capacity was questioned, how the resident was supported, who was consulted where practicable, the best-interest rationale, risks considered and any restriction used.

Where urgent restrictions are used to prevent harm, the on-call person must ensure that the Registered Manager is informed and that the need for a DoLS application, review of an existing authorisation, safeguarding referral or care plan review is considered promptly.

Staffing Contingency and Safe Deployment

The on-call person must treat any staffing shortage, unexpected absence, unsafe skill mix or dependency increase as a potential safety risk. The on-call person must consider the number of residents, dependency levels, known risks, layout of the home, staff competence, night-time risks, nursing requirements where applicable, medicines responsibilities, moving and handling needs, one-to-one support, end-of-life care and any resident requiring enhanced observation.

Where staffing may be unsafe, the on-call person must take immediate action, which may include redeploying staff, contacting additional staff, authorising agency cover, escalating to the Registered Manager or provider, pausing non-essential tasks, seeking professional advice, implementing business continuity arrangements, or notifying commissioners where the risk may affect safe service delivery.

Any decision to operate below planned staffing levels must be risk assessed, authorised, time limited, recorded and reviewed. The record must explain why the arrangement was considered safe or what additional controls were put in place.

Records, Confidentiality and Access to Information

The on-call person must have secure and lawful access to the information required to make safe decisions. This may include care plans, risk assessments, emergency contacts, DNACPR/ReSPECT information where applicable, medicines information, dependency information, staffing rotas, professional contacts and relevant policies.

All information accessed or shared during on-call duties must be handled in line with confidentiality, UK GDPR, the Data Protection Act 2018 and {{org_field_name}}’s information governance policies. Information must only be shared where necessary, lawful and proportionate, including where sharing is required to protect a resident or others from harm.

The On-Call Log must be factual, dated, timed and signed or electronically attributable. It must include the name of the person calling, the resident or issue involved, advice given, decisions made, escalation completed, persons contacted, notifications considered, follow-up required and confirmation that relevant care records or incident records have been updated.

Support, Supervision and Wellbeing for On-Call Staff

On-call staff must receive regular supervision, support and debriefing. Supervision must include review of decision-making, escalation, record keeping, safeguarding actions, statutory notifications, Duty of Candour considerations, emotional impact and learning from incidents.

Where an on-call person has managed a serious incident, death, safeguarding concern, distressing event, complaint, staffing crisis or emergency service attendance, the Registered Manager must offer timely debriefing and support. Where required, the provider must consider occupational health, counselling, reflective supervision or temporary adjustment of duties.

On-call rotas must be planned in advance and must take account of rest, fatigue, working time, competence, experience and the complexity of the service. On-call staff must be able to escalate to a named senior person if they are unsure, overwhelmed, conflicted, unavailable or unable to safely manage the issue.

Resident, Relative and Representative Communication

Residents, relatives and representatives must be informed that {{org_field_name}} has out-of-hours management arrangements in place to support safe and responsive care. Information about how urgent concerns are managed must be available in the Service User Guide or equivalent information provided to residents and representatives.

Where an incident occurs out of hours, staff and the on-call person must ensure that the resident and/or relevant person is informed in a timely, compassionate and lawful way, taking account of consent, confidentiality, best interests, safeguarding requirements and Duty of Candour.

The on-call system must not be used to unnecessarily restrict residents’ rights to receive visitors or to take visits outside the care home. Any urgent visiting restriction must be lawful, proportionate, risk assessed, time limited, clearly recorded and escalated to the Registered Manager for review.

Monitoring, Audit and Quality Improvement

The Registered Manager must review on-call records at least weekly, or more frequently where risk indicates. The review must check whether:

• Calls were answered and responded to promptly
• Advice and decisions were appropriate and proportionate
• Emergency services, health professionals, safeguarding and other agencies were contacted where required
• Incidents were recorded correctly
• Care records were updated
• Statutory notifications to CQC were considered and submitted where required
• Safeguarding referrals were made where required
• Duty of Candour was considered and completed where required
• Staffing risks were identified, escalated and resolved
• Any medicines, falls, infection control, missing resident, fire, environmental or business continuity issues were followed up
• Residents and/or representatives were informed where appropriate
• Learning was identified and embedded into practice.

Themes and trends from on-call logs must be reviewed through the provider’s governance systems. This includes analysis of repeated staffing shortages, frequent falls, medicines errors, delayed escalation, repeated night-time incidents, complaints, safeguarding concerns, hospital admissions, emergency service calls and any failures in the on-call system.

Actions arising from on-call audits must be recorded, allocated to a responsible person, given a timescale and reviewed to completion. Learning must be shared with staff through handovers, supervision, team meetings, training, policy updates and care plan reviews.

Business Continuity and Emergency Backup

A secondary on-call contact must be identified for every on-call period. The secondary contact must be competent, authorised and able to support or take over on-call duties if the primary on-call person is unavailable, unwell, unable to respond, has no signal, has a technical failure or is already dealing with another serious incident.

The on-call system must include contingency arrangements for:

• Mobile phone failure
• Loss of signal
• IT or electronic care planning system failure
• Power failure
• Fire, flood, heating failure, water failure or environmental emergency
• Severe weather
• Staff unable to attend work
• Agency staff failure
• Infectious disease outbreak
• Cyber incident affecting access to records
• Evacuation or partial closure of the home
• Sudden absence of the Registered Manager or other key person.

Emergency contact details must be checked regularly and whenever there is a change in personnel or service arrangements. The business continuity plan must be tested periodically, and any learning must be recorded and acted upon.

6. CQC Assessment Framework Evidence

{{org_field_name}} will retain evidence to demonstrate that the on-call system supports safe, effective, caring, responsive and well-led care. Evidence may include:

• On-call rotas
• On-call logs
• Incident and accident records
• Safeguarding referrals
• CQC statutory notifications
• Duty of Candour records
• Staffing contingency records
• Agency authorisations
• Resident care record updates
• Communications with relatives, representatives and professionals
• Emergency service records
• Business continuity activations
• Audit reports
• Governance meeting minutes
• Lessons learned records
• Staff supervision and debrief records
• Training and competency records for on-call persons
• Evidence of learning disability and autism training appropriate to role.

The Registered Manager must ensure that evidence is available, accurate, secure and capable of demonstrating how risks are identified, escalated, managed, reviewed and used to improve care.

7. Policy Review

This policy will be reviewed at least annually and sooner where there is a significant incident, safeguarding concern, complaint, regulatory change, CQC guidance update, change in service model, change in management structure, change in on-call arrangements, or evidence that the policy is not operating effectively.

The Registered Manager is responsible for ensuring that staff are informed of any changes to this policy and that relevant training, competency checks, supervision and governance processes are updated accordingly.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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